Program Director Checklist for Site Visits Updated: 3/2016

Program Director Checklist for Site Visits updated: 3/2016

PD’s complete this checklist at each assigned site once every month. Use one form per site. Forward completed PD Checklists to the Director of Operations. On-Site Visit/Inspection Site Name: ______Date: Alarms are armed upon arrival? Yes No What is the staff doing upon arrival? Medication Administration Record Sheets All boxes have documentation? Yes No PRN Meds documented correctly? Yes No New Medications transcribed correctly? Yes No Med cabinet is well organized, clean and not old/expired meds are present? Yes No Primary Checklists are complete with correct goals? Yes No Hand/foot checks and weight completed? Yes No Spot check DSP and Overnight Checklists – Tasks Complete? Yes No Comments:

Review the Banking Ledger for each Resident. Are they being completed daily M-F?: Yes No Comments:

Check Program Schedule: Current weekly activity schedule is posted? Yes No Is scheduled activity happening? Yes No Are activities specific to each resident and do activities change from week to week? Yes No Is the staff schedule updated and posted? Yes No Is menu planning by the residents taking place/current menu posted? Yes No Check Refrigerator/Freezer, cabinets, pantry – clean and adequate amount of food including Yes No fresh produce? Notice Resident Hygiene – is it acceptable? Yes No Comments:

Check for Cleanliness Inside: Room Checks – Is there food, garbage, safety hazards? Yes No Clothes on the floor? Yes No Common areas tidy – no clutter? Yes No Bathrooms clean? Yes No Floors clean? Yes No Beds have clean sheets, pillows, pillow cases, blankets? Yes No Outside: Lawn mowed/ walkways and driveways shoveled? Yes No Cigarette butts on ground? Yes No Garbage or other items in the yard? Yes No Maintenance Issues Observed: Was a work order submitted? For any “No” answers above, please describe any corrective action taken or planned to correct the concern:

List Staff Position Vacancies:

______Program Director Signature/Date